By Betty Tran, MD, MSc
Associate Professor of Medicine, Division of Pulmonary and Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago
SYNOPSIS: In this thematic analysis of a previously conducted randomized clinical trial, disparate shared decision-making behaviors were observed among meetings with white vs. Black caregivers of critically ill patients, illustrating opportunities for future clinician-level interventions.
SOURCE: Ashana DC, Welsh W, Preiss D, et al. Racial differences in shared decision-making about critical illness. JAMA Intern Med 2024;184:424-432.
This thematic analysis aimed to compare how intensive care unit (ICU) clinicians approach shared decision-making with Black vs. white caregivers of critically ill patients, focusing specifically on the issue of prolonged mechanical ventilation as the example.
Using data from a randomized, multicenter clinical trial conducted between 2012 and 2017 of medical and surgical ICUs, a total of 40 meetings (20 with Black caregivers and 20 with white caregivers) were transcribed and analyzed until thematic saturation was reached, where no new themes were identified. (One white caregiver meeting not analyzed because of poor recording quality.) The transcripts were coded and reviewed by a multidisciplinary team, and clinician behavior patterns were identified.
Overall, both Black and white caregivers were similar in terms of age, predominantly female, and possessed high levels of self-assessed health literacy. The duration of meetings was similar between groups. The study identified four areas where clinicians’ approach to shared-decision making differed between Black and white caregivers: disparate empathy toward caregivers in that Black caregivers received empathetic statements that were brief and generalized compared to long and personalized statements to white caregivers; Black caregivers often expressed trust and gratitude to the medical team that went unacknowledged compared to white caregivers who received affirmation when they did verbalize trust; clinicians shared less medical information with Black caregivers even when they expressed health-related knowledge; and inconsistent validation of treatment preferences where clinicians more readily supported decisions of white caregivers compared to Black caregivers, whose treatment preferences often were restorative rather than palliative care.
COMMENTARY
This study adds to the growing literature, expertly summarized in Dr. Chen’s Special Feature for this issue, regarding racial disparities at various levels in the ICU, ranging from patients’ clinical presentation to their management and overall outcomes. It also highlights three notable issues: disparate care and behaviors can certainly occur at the individual level (in addition to the hospital and community level highlighted by Dr. Chen); at the individual level, these behaviors likely reflect unconscious biases; and this study’s findings can lead to future targeted interventions to enhance our ability to become better allies with caregivers with the goal of equitable shared decision-making and outcomes for patients.
In their discussion, the authors refer to a “racialized empathy gap” whereby we empathize most strongly with those who are familiar. They also acknowledge the presence of “epistemic injustice,” whereby white caregivers are thought to have health literacy by the way they present themselves to the healthcare system compared to Black caregivers, where the same level of understanding/fluency is perceived as less credible and even threatening to the clinician’s expertise. These observations are important to acknowledge and accept. Knowing that, it will be vital to re-examine whether our current strategies of teaching empathetic communication result in benefit to all patients/caregivers. The study’s findings also provide specific targets for future intervention, which will need to be studied in the context of patient/caregiver desired responses, validated in larger samples, and assessed regarding impact on patient and caregiver-reported outcomes.
The study does have several limitations to consider. Importantly, it was unable to evaluate nonverbal communication, and clinician demographics (race, sex) were not considered as factors regarding shared decision-making, which is especially important since no clinician conducting these caregiver meetings identified as Black. It would be interesting to explore the dynamics of clinician-caregiver meetings with a larger pool of participants where both clinician and caregiver are Black, or the clinician is Black and the caregiver is white.
Overall, this study identifies a gap/need to improve the clinician’s ability to provide equitable shared decision-making support to caregivers of critically ill patients. It also highlights the importance of improving and maintaining diversity in the medical field to provide optimal, empathetic, goal-concordant care for the diverse population we serve.
